Coronavirus (COVID-19) for Nursing Professionals in Post-

Acute Care
Author: Chris Caulfield MSN, RN, NP-C

Last updated: 04-06-2020

The Origin of COVID-19

COVID-19 is the official name for a new infectious respiratory disease. This disease has spread rapidly
around the world since an outbreak was first identified in December 2019 in a city in central China called
Wuhan. The outbreak of this illness has been so swift, widespread, and significant that it is now
recognized by the World Health Organization (WHO) as a pandemic.(WHO)

COVID-19 is caused by a new type of coronavirus called SARS-CoV-2. Coronaviruses are a common family
of viruses that can infect both animals and humans. Researchers believe SARS-CoV-2 is a zoonotic virus,
meaning it evolved in animals first, such as bats and pangolins (a type of anteater), before jumping to
humans, possibly due to handling, trading, and consumption of wildlife in Wuhan's live animal
markets.(WHO)

As of early April 2020, there are over 1.2 million confirmed cases of COVID-19. More than 65,300 people
have died as a result of the illness, and over a quarter million people have recovered. The pandemic is
ongoing and actively developing, and countries around the world are taking drastic measures to slow
the spread of SARS-CoV-2 and avoid overtaxing hospital systems. This includes initiating social distancing
policies, closing down schools and nonessential businesses, and encouraging people to wear cloth masks
when going out in public.(CDC)

Many healthcare facilities, including skilled nursing facilities (SNFs) and assisted living facilities (ALFs) are
also initiating new regulations to protect residents and patients. Unfortunately, older adults and anyone
with chronic health conditions including cardiovascular disease, diabetes, or chronic obstructive
pulmonary disease (COPD)—who make up a significant portion of SNF and ALF populations—seem to be
at a greater risk for experiencing severe illness if infected by SARS-CoV-2.(CDC)

How COVID-19 Spreads

COVID-19 is a highly infectious respiratory disease. It is not the disease itself which spreads, but rather
the virus that causes the disease, called SARS-CoV-2.

SARS-CoV-2 can be found in the saliva of infected people, and spreads mainly through person-to-
person contact. When an infected person sneezes, coughs, or even breathes or talks, infectious droplets
of saliva can be emitted into the air. Another person can then become infected if they inhale these
infectious droplets directly, or possibly by touching a surface contaminated by these droplets and then
touch their mouth or nose. Studies indicate that the SARS-CoV-2 virus can survive on hard surfaces like
plastic and stainless steel for up to three days, on cardboard for up to 24 hours, and on copper for up to
four hours.(NEJM) Fortunately, regularly cleaning and disinfecting these surfaces is effective for
removing and destroying the virus, respectively.(CDC)

The virus is also detectable in the air for up to three hours. According to the WHO, airborne spread is
not thought to be a major cause of transmission. However, airborne spread could be possible during
certain aerosol-generating medical procedures often performed in healthcare facilities, such as
nebulizer treatments and suctioning.(WHO) Similarly, samples of the virus have been found in fecal
samples of some patients, although fecal-to-oral transmission isn't thought to be a key driver of the
pandemic, either.

Once inside the body, the virus can attack the respiratory system. In severe cases, the virus can cause
lung damage which makes it difficult for oxygen to be transported from the lungs and into red blood
cells; this is a potentially fatal complication known as acute respiratory distress syndrome
(ARDS).(Cleveland Clinic) People with severe cases of COVID-19 may also experience heart failure,
possibly due to widespread systemic inflammation or high lung pressure which can damage the
heart.(Mayo Clinic)

Sign and Symptoms of COVID-19

It's important to realize that SARS-CoV-2 can still be spread by infected people even if these people
are asymptomatic (showing no symptoms). If symptoms do develop, they are usually mild and develop
slowly. The most commonly reported symptoms of COVID-19 include fever, shortness of breath, and
cough. Less commonly, people may experience nasal congestion, runny nose, sore throat, stomach pain,
and diarrhea.(CDC) These symptoms show up between 2 and 14 days after a person is first infected. This
delay in symptom onset is known as the incubation period; infected individuals can still spread the
virus to others during this time.

Based on current research, the majority (about 80 percent) of people who contract COVID-19 will have
mild or no symptoms and recover without the need for hospitalization or any specialized medical
care.(The Lancet) A smaller portion of people who contract COVID-19 will require hospitalization and
possible admission to an intensive care unit and mechanical ventilation. The following people are more
at risk for having severe symptoms and complications of COVID-19, including death (which occurs in
about 2 percent of all cases):(CDC)

• Older adults (aged 65 and up)

• People who live in long-term care facilities and nursing homes
• People who smoke
• Anyone with a compromised immune system
• People with underlying chronic health conditions, including diabetes, obesity, heart disease,
hypertension, restrictive lung diseases (e.g., asthma or COPD), chronic kidney disease, and liver
disease

Children can also develop COVID-19. Fortunately, it's uncommon for children to experience
complications or anything more than mild symptoms.

Diagnosis and Treatment of COVID-19

Doctors can diagnose people with COVID-19 by assessing their symptoms and risk exposure, as well as
by obtaining a sample of their saliva and sending it to a laboratory for testing. Not everyone is being
tested, however. The Centers for Disease Control and Prevention (CDC) has provided criteria of who
should be tested.(CDC) Based on this criteria, clinicians are encouraged to test people in the following
order of priority and as resources allow:

• Hospitalized patients and symptomatic healthcare workers

• Symptomatic residents of long-term care facilities, symptomatic people who are older than 65
and/or have underlying chronic health conditions, and symptomatic first responders
• Symptomatic critical infrastructure workers, any symptomatic individuals who don't fit the
above categories, asymptomatic healthcare workers and first responders, and individuals with
mild sympotms in communities where transmission and hopsitalization rates are high

Right now, there aren't any vaccines or specific treatments that can be used to treat COVID-19. Hospitals
can provide supportive care to people who are severely ill with COVID-19, and doctors and researchers
are currently experimenting with a range of drugs including antiviral drugs, antimalarial drugs,
autoimmune disease drugs, high-dose Vitamin C, and antibodies from the blood of people who have
already recovered from COVID-19.(Harvard Medical School)

Infection Control: Best Practices

At this point, experts and health officials are urging communities to take action to reduce the rate of
transmission of COVID-19 ("flatten the curve"). Projections indicate that reducing transmission rates can
prevent hospitals from having their spaces and resources overwhelmed, since not as many people will
be getting severely sick all at once, but rather will be more spread out over a longer period of
time.(NPR)

For nurses and other healthcare providers working in SNFs, ALFs, and similar settings, there are several
best practices, supported by the CDC and other organizations, to reduce transmission and keep patients,
residents, and caregivers safer. Attentive and strict adherence to infection control policies and proper
use of personal protective equipment (PPE) are among the most critical action steps that can be taken.
Here's how this may look:(CDC)(CDC)(CDC)(CDC)(WHO)

Promote Excellent Hygiene Techniques by All Caregivers, Residents, and Visitors

• Wash hands for at least 20 seconds with soap and water before and after contact with residents,
after contact with contaminated surfaces or equipment, and after removing PPE, before eating,
after going to the bathroom, after coughing, sneezing, or blowing your nose, and whenever
hands are visibly dirty.
• Soap and water is best and preferable for hand hygiene, but when it is not available use alcohol-
based hand sanitizer. Hand sanitizers should be placed inside and outside every resident room,
as well as hallways, nursing stations, and other areas within a facility.
• Keep hygine supplies well-stocked at all times, especially soap and paper towels at sinks.
• Avoid touching your face, eyes, nose, and mouth. The prompt "keep your hands below your
neck" can help you remember to avoid touching these areas of your body.
• Cover every cough or sneeze with a single-use disposable tissue. If a tissue is unavailable, cough
into your elbow.
 • Frequently clean and disinfect objects and surfaces using approved hospital disinfectants. This
includes tables, countertops, lightswitches, hand rails, door handles, computer keyboards, and
medication carts.

Monitor Residents for Symptoms

• Residents who have fever or new respiratory symptoms should be restricted to their rooms with
the door closed, until further guidance from local health department. If they have to leave for
medically-necessary procedures, they should don a facemask and wash their hands first.
• Residents with any undiagnosed respiratory infections should be cared for using Standard,
Contact, and Droplet precautions, or Airborne precautions if indicated.
• Any suspected cases of COVID-19 should be brought to the attention of local and/or state public
health officials to ensure appropriate guidance and management.

Provide Appropriate PPE and Ensure Appropriate PPE Utilization

• Keep appropriate PPE (including gowns, gloves, eye protection, face masks, caps, and booties)
immediately available, either outside resident rooms or at a designated spot near the nursing
station.
• Post clear signs on doors and walls outside a resident's room to indicate the type of precautions
and PPE required prior to entering.
• Place disposal bins and trash cans conveniently nearly the exit of a patient's room to make it
easy to discard PPE upon leaving.
• According to the updated guidelines from the CDC, general precautions for low-risk patient care
of suspected COVID-19 individals have been downgraded from Airborne to Droplet. This is due
to low evidence of airborne transmission of SARS-CoV-2 in normal circumstances and due to
limited supplies of N95 masks. Surgical masks (along with gowns and gloves) are appropriate in
these instances.
• Airborne precautions (including N95 masks and face shields) are indicated during respiratory
treatments for individuals suspected of COVID-19, since such treatments (nebulizers, suctioning,
trachestomy care, and application or adjustment of oxygen masks and nasal cannuli) may
reasonably lead to aerosolization of infectious droplets. Prior to any respiratory treatments for
patients who are not suspected to have COVID-19, providers should don surgical masks, eye
protection, and face shields (in addition to gowns and gloves).
• Healthcare providers must be fit tested for N95 respirator face masks and should speak with
employee health personnels to ensure appropriate assessment and fit.
• In the event of low resources, healthcare providers should speak directly with their supervisors
or employee health personnel regarding handling of PPE, or refer to current local, state, and
federal guidelines.
• Ton don PPE prior to working with suspected COVID-19 individuals:
o Perform hand hygiene
o Put on isolation gown
o Put on N95 mask
o Put on face shield or eye protection
o Perform hand hygeiene
o Put on gloves (healthcare providers may now enter the room)
• To doff PPE after working with suspected COVID-19 individuals:
 o Remove gloves, ensuring there is no additional contamination of hands
o Remove gown (healthcare providers may now exit the room)
o Perform hand hygiene
o Remove face shield or eye protection
o Remove and discard face mask, being sure not to touch the front of the mask
o Perform hand hygiene

Encourage Employee Responsibility

• Remind all caregivers that any employee who is feeling sick should stay home and consult with
their primary healthcare provider and/or employee health representative.
• Direct patient caregivers and staff members should be screened for symptoms, risk
exposure, and fevers by supervisors, nursing managers, or other personnel prior to the start of
any shift, especially in areas with documented community spread of COVID-19.

Adjust Visitor Policy

• Many SNFs, ALFs, hospitals, inpatient rehabilitation facilities, and other healthcare facilities are
prohibiting visitors other than for under limited and specific exceptions.
• If visitors are allowed at a facility, visitors should be screened by personnel.
• Warning signs, "stop" signs, and direct communication with visitors, family members, and
residents or patients should be made available to help people be aware of and compliant with
current visitor policies.

Summary
The COVID-19 pandemic is an actively evolving scenario. Changes with guidelines, policies, and
recommendations are happening on a near-daily basis. Staying as up-to-date as possible by referencing
reliable resources is important for keeping everyone safer.

For healthcare providers in SNFs, ALFs, and related facilities, the key concepts for reducing transmission
include: limiting how many germs and viruses can get into the facility; isolating symptomatic residents
and patients; and protecting healthcare personnel by ensuring appropriate use of PPE. Nurses and other
providers are always encouraged to use their best judgment, speak with their supervisors, and consult
with public health authorities, including state and local health departments and the CDC.

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